DSM-V Badly Off Track

According to Ken Pope, that’s the title of an interview with Allen Frances at Psychiatric Times. Dr. Frances was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke. I’m passing on the excerpts that Dr. Pope culled from the article:

Q: This is the first time you have commented on DSM-V. Why did you decide to speak up now?

A: We have already gone past the midway point of the time allotted for the preparation of DSM-V. I realized that not enough has been accomplished and that most of what is being suggested is headed in a very wrong direction. Particularly troubling is the almost total lack of recognition that changes in an official manual of diagnosis can have devastating unintended consequences. Before it is too late, I feel a responsibility to help DSM-V avoid mistakes by sharing the lessons learned during the past 30 years working on the 3 previous revisions of the DSM. Perhaps my comments may help the DSM-V Task Force avoid some of the hidden landmines I think they are dancing around.

Q: In your opinion, what has gone wrong in the DSM-V process?

A: The most fundamental errors have been its completely inexplicable secrecy and the lack of openness to outside influence and criticism. I simply can’t recall a single moment of work on the DSM-III, DSM-III-R, or DSM-IV when there was anything remotely worth keeping secret. Restricting the free flow of ideas creates enormous blind spots that greatly increase the risk of damaging unintended consequences. Specifically, it was a huge mistake to require that the DSM-V work group members sign a confidentiality agreement. It was also unwise to avoid having any institutional memory of how and why decisions were made in prior revisions. The advisory group is far too small and select to reduce, rather than encourage, heated debate. In producing a new edition of the DSM, your harshest critics eventually turn out to be your best friends because they are most likely to help you avoid pitfalls. My own highly critical comments on DSM-V are offered, and I hope will be taken, in this spirit.

Q: What are the risks you are so concerned about?

A: The work on DSM-V suffers from the unfortunate combination of being heavy on ambitious goals for change and light on the methodological rigor necessary to avoid the many problems that such change may cause once the system is in wide use. Unless DSM-V changes course dramatically, it will introduce numerous new, relatively untested categories that will greatly jack up the rates of mental disorders. Many people will be inappropriately identified as mentally ill and will receive excessive treatment. The pharmaceutical industry will have a field day. Two necessary forms of protection should have been established to prevent this: (1) a requirement that all changes be supported by a high threshold of systematically gathered empirical evidence, and (2) a careful risk-benefit analysis of the potential negative impact of each and every change.